MEDICARE: DOUGLAS A KELLOGG DDS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1730351917
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOUGLAS A KELLOGG DDS PA

Provider Business Mailing Address
First Line	:	2733 HORSE PEN CREEK RD
Second Line	:	SUTIE 107
City	:	GREENSBORO
State	:	NC
Zip	:	27410-8399
Country	:	US
Telephone Number	:	336-854-9270
Fax Number	:	336-854-5628

Provider Business Practice Location Address
First Line	:	2733 HORSE PEN CREEK RD
Second Line	:	SUTIE 107
City	:	GREENSBORO
State	:	NC
Zip	:	27410-8399
Country	:	US
Telephone Number	:	336-854-9270
Fax Number	:	336-854-5628

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DOUGLAS ALAN KELLOGG
Credential	:	DDS
Telephone Number	:	336-854-9270

Provider Enumeration Date	:	03/28/2008
Last Update Date	:	03/28/2008

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